The ABC’s in Pediatric

Assessment and Care

Cymbeline Joan L. Pooten, RN
NUM – Pediatric ICU
 SLMC definition of
Pediatric Age shall be…
Newborn to 18 years and 364 days.
 Developmental Stages
 Neonatal – 0 to 28 days
 Infancy – 29-11 months
 Toddler – 1 - 3 years
(PRAISE)
 Pre-School – 3 – 6 years
(MAGIC)
 School Age – 6 - 12
years (DIMPLE)
 Adolescent – 12- 18
years (PAIRS) 364 days
NEONATAL ASSESSMENT
FOUR PHASES

1.Delivery Room

2.NurseryAdmission

3.Daily Assessment

4. Discharge
 DELIVERY ROOM

Assess for the following:

a. Gross Appearance
b. APGAR Score

Purposes of APGAR Scoring

a. evaluate condition of baby at birth
b. determine need for resuscitation
c. evaluate effectiveness of
d. resuscitative after birth
 0 1 2

ACTIVITY LIMP SOME ACTIVE

FLEXION
PULSE ABSENT <100 >100

GRIMACE NONE GRIMACE CRY &

GRIMACE
APPEARANCE BLUE PINK COMPLETE
BODY LY PINK
BLUE
EXT.
RESPIRATION ABSENT SLOW, GOOD
IRREG. STRONG
CRY
 APGAR Scoring
 At the delivery room
• APGAR Scoring: A clinical appraisal of
the newborn recorded at 1 minute and 5
minutes
• The 1 minute scoring: an index of the
necessity of resucitation.
• The 5 minutes scoring: valuable in
predicting mortality and neurologic
deficits of the surviving infants at one
year
 APGAR Scoring
 Score  Intervention
 7 – 10 minutes  Vigorous

 4 – 6 minutes  Vigourous
stimulation;
assisted ventilation

 0 – 3 minutes  Immediate
intubation
NURSERY
 At the Nursery
 Ballard Scoring  Antrophometric
• Maturity rating and measurement
classification • Weight – daily
• One of the most • Birth Length – upon
vividly used tests admission
for determining • Head Circumference
gestational age or – do
estimate the
• Chest
physical maturity of
circumference – do
the newborn
 At the Nursery
 Vital signs  In circumstances in
• Temperature: taken which pathologic
rectally condition is
• To check for suspected; these
patency of the anus anthrophometric
measurement is
taken more
frequently
 Vital Signs
 Temperature - range 36.5 to 37
axillary
 Heart rate - range 120 to 160 beats
per minute
 Respiration - range 30 to 60 breaths
per minute
 Blood pressure –done routinely normal
value based on age group
 Blood Pressure
 Minimum diastolic BP = 2/3
systolic BP

 Minimum systolic BP = 70 +
2 x (age in years)
Pain:the 5th Vital Sign
 FLACC SCALE
( FACE,LEGS,ACTIVITY,CRY,CONSOLABILITY)
0 1 2
No particular Occassional grimace Frequent to constant
expression or smile or frown, withdrawal, frown, clenched jaw,
FACE disinterested quivering chin

Normal position Or Uneasy, restless, Kicking or Legs drawn

tease up
LEGS relaxed

Lying quietly Squirming Shifting Arched

Normal position back/forth Rigid or Jerking
ACTIVITY Moves easily Tense

No cry Moans or Whimpers Crying Steadily

(Awake or Asleep) Occassional Complaint Screams or Sobs
CRY Frequent Complaints

Content Reassured by Difficult to console or

CONSOLABILITY Relaxed occasional comfort
touching,hugging or
talking to
Distractible
 Urine Output
 I&O
 Urine Output – ml/kg/hr
 Formula :

Total Urine Output

(ml)/weight/total # of
hours
 Diaper wet : 1 mg = 1 ml
 General Measurements
 Head circumference 33 - 35cm
Expected findings
Head should be 2 to 3 cms larger than
the chest
 Chest circumference 30.5 - 33cm
 Weight range 2500 - 4000 gms (5 lbs.
8oz. - 8 lbs. 13 oz.)
 Length range 48 - 53 cms (19 - 21 in)
 Infancy
0 – 3 mos – Recliner. His
head lags
Totally dependent
3 – 6 mos – Sitter. Starts
rolling over at 6 mos. Can
sit for short periods of time
leaning forward on hands.
6 – 9 mos – Bouncer or
Crawler. Can pull self to
sitting position. They start
boncing so much that they
bounce out and start
crawling by 8 – 9mos.
Everything goes in the
mouth
 TODDLER
( 1-3 years old)
 The “NO-NO” period
 P – push – pull toys,
Parallel play
 R – rituals and
routines, regression
 A – autonomy
,accident
 I – Involve parents
 S – separation anxiety
 E – Elimination (toilet
training), Exploring
 Pre-School (3-6 years)
 The word that is
characteristic of
this stage is “WHY”
 M – mutilation
 A – associated play
 G – guilt
 I – Initiative;
Imaginary
playmate
 C - curiosity
 School Age (6-12 years)
 D – death
 I – immunizations,
industry vs
inferiority
 M – modesty
 P – peers
 L – loss of control
 E – explanation
procedures
 Adolescent ( 12-18 years and 364
days)
 They are usually seen in PAIRS
 P – peer group
 A – altered body image
 I – identity
 R – role diffusion
 S – separation from peers
 Mnemonics
A.WEIGHT
Average birth weight = 3kgs
 For infant below 6 months of age

• Wt in grams = Age in mos x 600 + BW

 For infants 6 – 12 months
• Wt in gms = age in mos x 500 + BW
 For children 2 years and up
• Wt in kg = Age in yrs x 2 + 8
 Mnemonics
B.Birth length
 From birth to 3 mos = 9 cm

 3 – 6 mos = 8 cm

 6 – 9 mos = 5 cm

 9 to 12 mos = 3 cm

 Ht in cm = age in years x 5 + 80

 Ht in inches = age in yrs x 2 + 32

 Mnemonics
C.Head Circumference
 For the 1
st year of life

• First 4 mos = ½ inch/mo = 2 inches

• Next 8 mos = ¼ inch/mo = 2 inches
• Second year = 1 inch
• 3rd to 5th year = ½ inch/yr = 1.5 inches
• 6th to 12th year = ½ inch/5yrs = 1.5 in
 Importance
 In pediatrics, it is important to take
note of these because it will tell us if
the patient is
• Malnourish
• Wasting
• Stunting
• Hydrocephalus
• Hydration status
 PEDIATRIC APPOXIMATE SIZE AND NORMAL VALUES CHART

AGE WT. RR HR BP SUCTI LARYN TRA NG FOL CHE

(kg.) (bp (bp systoli ON GO ETT CH T EY ST
m) m) c Cathet SCOPE size (Fr. (Fr.) TUB
(mmHg er (Fr.) (mm ) E
) ) (Fr.)
Premi <3 <6 14 52 ± 6 0 2.5- 00 5 5 10
e 0 0 10 Miller 3.0

Newb 3-4 <6 12 60 ± 8 0 3.0- 0 8 5 10-

orn 0 5 10 Miller 3.5 12

1–6 4-6 24- 14 80 ± 10 1 3.5- 0-1 8 8 10-

mo 30 0 10 Miller 4.0 12

6 – 12 6-10 13 89 ± 10 1 4.0 1-2 8 8 12-

mo 5 25 Miller 20

1–2 10- 24- 12 96 ± 10 1 4.5 1-2 8 8-10 16-

yr. 13 24 0 30 Miller 20

2–4 13- 11 99 ± 10-14 1-2 5.0 2-3 8- 10 20-

yr. 17 0 25 Miller 10 24

4–6 17- 10 100 ± 14 2 5.5 3 10 10 24-

yr. 20 0 20 Miller ± 28
cuff
6–8 20- 12 10 105 14- 2 6.0 3-4 10 10- 28
yr. 25 - 0 ±13 16 Miller cuf 12
20 fed

8– 25- 90 110 ± 16 2 6.0- 4 10 12 28-

10 yr. 30 15 Miller 7.0 - 32
cuf 12
fed

10 – 30- 80 112 ± 16 2 7.0 4-5 12 12 32

12 yr. 40 15 Miller cuf
2 Mac fed

12 – 40- 80 115 ± 16 2-3 7.0- 5-6 12 12 32-

14 yr. 50 20 Miller 7.5 36
2-3 cuf
Mac fed

14 - >50 10 70 120 ± 16 3 7.5- 6 14 12 36-

adult - 20 Miller 8.0 42
14 3 Mac cuf
fed
 Are you SMART?
We are…in PEDIATRICS!
S ignature in your charts
-Have you sined all 6 forms in your chart and your orders?
M easure your fluids, drugs
- Have you computed drug dosages/fluid requirement properly?
A rticulate your orders
- Have you communiated with residents and nursing staff regarding
orders?
R elate to your patient, customer care
-have you discussed the case with your patient, given written
discharges, instructions and follow-up?
T imeliness
-Are you punctual in accomplishing the forms in your chart?
-Have you accomplished the professional fee form with adequate time prior to
discharge?
 Are you SMART?
We are… in PEDIATRICS!
S ignature in
your charts
-Have you
signed all 6 forms
in your
chart and your
orders?
 Are you SMART?
We are… in PEDIATRICS!
M easure your fluids, drugs
-Have you computed drug
dosages/ fluid requirement properly?
 Are you SMART?
We are… in PEDIATRICS!
A rticulate your orders
- Have you communicated with
residents and nursing staff regarding
orders?
 Are you SMART?
We are… in PEDIATRICS!
R elate to your patient,
customer care
- Have you discussed the case
with your patient, given written
discharges, instructions and follow-
up?
 Are you SMART?
We are… in PEDIATRICS!
T imeliness
- Are you punctual in accomplishing
the forms in your chart?

- Have you accomplished the

professional fee form with adequate
time prior to discharge?
 Listen Nurse
 I was hungry and I couldn’t feed myself,
you left my food tray out of reach on my
bedside table. Then you discussed my
nutritional needs during a nursing
conference.
 I was thirsty and helpless, but you forgot
to ask the attendant to refill my water
pitcher. You later charted that I refused
fluids.
 I was lonely and afraid, but you left me
alone because I was so cooperative and
never asked for anything
 Listen Nurse
 I was in financial difficulties and in your
mind, I became an object of annoyance.
 I was nursing a problem and you
discussed the theoretical basis of my
illness, and you did not even see me.
 I was thought to be dying, and thinking I
could not hear, you hope I would not die
before it was time to finish your day
because you have an appointment at the
beauty parlor before your evening date.
 Listen Nurse
 You seem so well educated, well spoken,
and so very neat in your spotless
unwrinkled uniform, but when I speak,
you seem to listen but not hear me…
 HELP ME CARE ABOUT WHAT HAPPENS TO
ME; I am so tired, so lonely, and so very
afraid!
 Talk to me… Reach out to me…. Take my
hand! Let what happens to me matter to
you… PLEASE NURSE
 Any
questions?